Week 9: Chapter 29 - Respiratory System Disorders - NRSE 2112 Hopgood/Harper

What are some risk factors of pneumonia?

Smoking

Multiple comorbidities

Older age

Kidney disease

Exposure to infections

SMOKE

What are the 3 classifications of pneumonia based on?

- Causative Agent

- Anatomical location of infection

- Epidemiological data

What are the three causative agents of pneumonia?

- Viral

- Bacterial

- Fungal

What is a nosocomial infection?

hospital acquired infection

What is VAP?

ventilator associated pneumonia

What is epidemiological data?

Data (facts/statistics) that relates to the occurrence, transmission, and control of diseases

What are the routes of infection for pneumonia?

- Aspiration (sucking it in)

- Inhalation

- Endotracheal tubes and suctioning

- Bacteremia in the lungs (traveled there through the blood)

What is aspiration?

Passage of fluid and solid particles into the lungs

What is bacteremia?

presence of bacteria in the blood

What are the clinical manifestations of pneumonia?

- Sudden onset

- High fever with chills, fatigue, and leukocytosis

- Dyspnea, tachypnea, tachycardia

- Pleural pain

- Rales (crackles)

- Productive cough

- Confusion and disorientation

With pneumonia, typically, what color is the sputum, and why?

- Rusty-colored sputum

- Exudate from inflammation and vascular congestion

What is empyema?

Pleural effusion containing infectious microorganisms

The client was diagnosed with pneumonia and has newly developed confusion and disorientation. The likely cause for the change in mentation is due to...?

Hypoxia

On average, for about each liter of oxygen, what % of oxygen are you giving to the patient?

1 liter = ~4% of oxygen

Room air = 21% oxygen

Therefore,

3 liters = ~12% -> 33% oxygen

What is the most non-invasive option for treating oxygen distress in COPD or pnuemonia patients?

Nasal cannula

What is the use of a nonrebreather mask?

To treat severe hypoxia or hypoxemia

What is SARS?

severe acute respiratory syndrome

How does SARS spread?

Transmission by AIRBORNE droplets- it will hang in the air!

What are the first signs of a SARS infection?

Fever, headache, myalgia, chills, anorexia, possibly diarrhea

Why is confusion a symptom in older persons normal in COVID-19?

Lack of oxygen, Hypoxia

What is the causative agent of Tuberculosis?

Mycobacterium tuberculosis

How is tuberculosis transmitted?

Airborne oral droplets from persons with active infection

What is primary or latent tuberculosis?

- Organsim first enters the lungs, and the bacilli is walled off; can remain dormant for years.

- Individual's cell-mediated immunity is adequate

- Simply, they become a asymptomatic and the individual cannot transmit the disease. NOT contagious!

What is secondary or active tuberculosis?

- If cell-mediated immunity is inadequate, Mycobacteria reproduce and begin to destroy the lung tissue

- This form of the disease is CONTAGIOUS

What is myalgia?

Muscle pain (muscle aches -> common with SARS)

Why does tuberculosis transition from primary to secondary?

Occurs when a client's cell-mediated immunity is impaired because of:

- Stress

- Malnutrition

- HIV Infection

- Age

During active TB, organisms multiply and form large areas of...?

Necrosis

How does cavitation promote the spread of TB into other parts of the lungs?

By creating a highly infectious environment and providing a direct conduit for bacteria to travel to other parts of the respiratory system. A cavity is a hole in the lung formed by the breakdown of tissue that erodes into an airway, which allows for a high bacterial load to be released and disseminated.

What is the treatment of TB?

- Long-term treatment with a combination of drugs. Treatment can vary from 6 - 12 months.

- Effective treatment requires monitoring and follow-up care is highly expensive.

What are some diagnostic tests of active TB?

- Acid-fast sputum test

- Chest radiography

- Sputum culture and sensitivity

What is cystic fibrosis?

It is a genetic disorder of the cell membranes. Causes a very thick, sticky mucus to build up in air passages and pancreas.

What infections are common in patients with cystic fibrosis?

Commonly caused by:

- Pseudomonas aeruginosa

- Staphylococcus aureus

In patients with cystic fibrosis... what happens to their sweat?

It has a high sodium chloride content

What are some signs and symptoms of cystic fibrosis?

- Meconium ileus may occur at birth

- Salty skin

- Signs of malabsorption

- Chronic cough and frequent respiratory infections

- Failure to meet normal growth milestones

What is meconium ileus?

A condition that occurs when a baby's first stool, meconium, blocks the past part of their small intestine.

What is steatorrhea?

excessive fat in stool: malabsorption as in cystic fibrosis.

How do you diagnose cystic fibrosis?

- Genetic testing

- Sweat testing

- Testing of stool

- Radiography

- Blood gas analysis

How do you treat cystic fibrosis?

- Replacement therapy and well-balanced diet

- Chest physiotherapy

Why do you focus on a well balanced diet in peoples with cystic fibrosis?

- The pancreas, it can't produce enough digestive enzymes or enzymes unable to reach intestines

What is asthma?

Bronchial obstruction due to chronic inflammatory disorder of the bronchial mucosa

What are hyper sensitive airways?

Increased sensitivity of airways to stimuli

What are hyper responsive airways?

An exaggerated immune response to triggers

What is the pathophysiology of asthma?

Persistent but variable inflammation of the airway. Airflow is limited because of inflammation results in bronchoconstriction, airway hyperresponsiveness, and edema of the airways.

What is extrinsic asthma?

- Allergic asthma that is triggered by external factors.

- Acute episodes triggered by type I hypersensitivty... ex: dust mites

What is intrinsic asthma?

- Nonallergenic asthma that is triggered by internal factors

- Onset during adulthood

- Hyperresponsive tissue in airway will initiate an attack

What are some stimuli of intrinsic asthma?

- Respiratory infections

- Stress

- Exposure to cold

- Inhalation of irritants

- Exercise

- Drugs

What happens in an early asthmatic response?

- Resolves within 1-2 hours

- Vasodilation

- Increased capillary permeability

- Mucosal edema

- Bronchial smooth muscle contraction

- Tenacious mucous secretion

What happens in a late asthmatic response?

- Happens 4-8 hours after early response

- Airway scarring

- Increased bronchial hyperresponsiveness

- Impaired mucociliary function

Primarily, what three pathophysiological events occur that causes the symptoms of asthma?

- Inflammation of the mucosa

- Bronchoconstriction

- Thick secretions

What is tenacious sputum?

Extremely sticky and viscous, making difficult to cough up and clear from the lungs.

What is COPD?

- Group of chronic respiratory disorders

- Irreversible and progressive damage to the lungs

- May lead to the development of cor pulmonale

What is cor pulmonale?

is defined as right ventricular hypertrophy with eventual RV failure resulting from pulmonary HTN, secondary to pulmonary disease.

What are the two most common causes of COPD?

- Chronic bronchitis

- Emphysema

What is Chronic Bronchitis?

1/3 of COPD cases; hypersecretion of mucus and chronic productive cough that continues for at least 3 months of the year for at least 2 consecutive years in the absence of other conditions that can explain these symptoms.

What is Emphysema?

Most common COPD cases; abnormal permanent enlargement of airways with destruction of alveolar walls resulting in loss of elastic recoil with collapse of airways during expiration

What is the difference between Chronic Bronchitis and Emphysema?

Chronic Bronchitis:

- Problem is in the airways (bronchi).

- They stay inflamed and full of mucus, making it hard for air to move in and out.

- Main symptom: productive cough for months/years.

Emphysema:

- Problem is in the alveoli (air sacs).

- They get damaged and lose elasticity, so air gets trapped and gas exchange is reduced.

- Main symptom: shortness of breath and air trapping, often with a barrel chest appearance.

What are some contributing factors to Emphysema?

- Genetic deficiency

- Genetic tendency

- Cigarette smoking

- Pathogenic bacteria

What happens during advanced emphysema?

- Damaged alveoli form large air spaces

- Pneumothorax occurs when the pleural membrane surrounding large blebs ruptures

- Hypercapnia

- Pulmonary hypertension

What are blebs?

Gas-containing spaces smaller than 1 cm within the visceral pleura

What are bullae?

Plural form of bleb

What is the main characteristic of emphysema?

- Barrel chest

- Increased anterior-posterior diameter of thorax

What are the signs and symptoms of emphysema?

- Dyspnea

- Hyperventilation with prolonged expiratory phase

- Anorexia and fatigue

- Clubbed fingers

What are the signs and symptoms of chronic bronchitis?

- Constant and productive cough

- Tachypnea and shortness of breath

- Frequent thick and purulent secretions

- Cough and rhonchi are more severe in the morning

- Hypoxia, cyanosis, hypercapnia, etc.

- Polycythemia, weight loss, signs of cor pulmonale possible

What is Rhonchi, and where is it heard?

Rhonchi are low-pitched, rattling, snoring-like lung sounds caused by obstructed or congested larger airways like the bronchi. This obstruction is typically due to mucus, fluid, or other secretions, and the sound is often heard in conditions such as chronic bronchitis, pneumonia, and COPD.

What is Rales, and where is it heard?

Rales, or crackles, are abnormal lung sounds that are heard during breathing as a result of air passing through fluid in the small airways. They are described as fine, high-pitched, clicking, or rattling sounds, similar to the sound of salt on a hot pan or cellophane being crumpled.

What is pulmonary edema?

fluid collecting in the alveoli and interstitial area

Pulmonary edema may develop when...?

- Inflammation in the lungs is present

- Plasma protein levels are low

- Pulmonary hypertension develops

When plasma protein levels are low, what happens to osmotic pressure?

Decreased osmotic pressure

When pulmonary hypertension develops, what happens to hydrostatic pressure?

Increases

With mild pulmonary edema, what are some signs and symptoms?

- Cough

- Orthopnea

- Rales (crackles)

With non-mild increased congestion pulmonary edema, what are some signs and symptoms?

- Hemoptysis

- Sputum is frothy and frequently PINK

- Increased dyspnea with hypoxemia

- Cyanosis develops in the advanced stage

What is a pulmonary embolus?

Blood clot or mass that obstructs pulmonary artery or any of its branches

90% of pulmonary emboli originate from what?

DVT in legs

Compare thrombus vs emobulus

- Thrombus: blood clot

- Embolus: travelling blood clot

What is the treatment for a pulmonary embolus?

Prevention of DVTs (PRIMARY TREATMENT)

Anticoagulant,

Thrombolytic drugs

Surgery

BED REST + COMPRESSION SOCKS

What is atelectasis?

Nonaeration or collapse of a lung or part of a lung, leading to decreased gas exchange and hypoxia.

What happens to the alveoli in atelectasis?

- Alveoli collapse, and inflammation or atrophy occurs, interfering with blood flow through the lung

What are some signs and symptoms of atelectasis?

- Small areas are asymptomatic

- Large areas include: dyspnea, increased HR & RR

What is pleural effusion?

- Excessive fluid within the pleural cavity, lung cannot expand due to the fluid

What is the use of a nasal cannula?

To treat mild hypoxia or hypoxemia

Pleural effusion leads to increased pressure within the pleural cavity which can lead to...?

Separation of the pleural membranes

What are some signs and symptoms of pleural effusion?

- Dyspnea

- Chest pain

- Increased respiratory and heart rates

- Usually, dullness to percussion and absence of breath sounds over the affected area

- Tracheal deviation and hypotension

What causes tracheal deviation in pleural effusion?

Pressure in one third space is building up so much that it is quite literally pushing the trachea and other viscera towards the other lung.

What is the treatment of a pleural effusion?

- FINDING THE ROOT CAUSE

- However, in the meantime, a thoracentesis to remove fluid and relieve pressure

What is a thoracentesis?

Insertion of a large bore needle through the chest wall into the pleural space to obtain specimen for diagnostic evaluation, remove pleural fluid, or instill medications into the pleural space.

Compare pleural effusion, pneumothorax, and atelectasis

Pleural Effusion: Fluid collects in the pleural space and compresses the lung, causing decreased breath sounds and dullness on percussion. Fluid issue.

Pneumothorax: Air enters the pleural space, collapsing the lung and leading to absent breath sounds with hyperresonance. Air issue.

Atelectasis: Part of the lung collapses internally due to blocked airways or shallow breathing, causing diminished breath sounds. Tissue issue.

What is a closed pneumothorax?

air can enter the pleural cavity from internal airways, no opening in chest wall

What is a simple or spontaneous pneumothorax?

tear on the surface of the lung

What is a secondary pneumothorax?

Caused by disease, trauma, injury, or condition

What is a hemothorax?

blood in the pleural space

What is an open pneumothorax?

Pneumothorax where air enters the pleural space through an opening in the chest wall. Stab, gunshot wounds, and surgical thoracotomy.

What is ARDS (acute respiratory distress syndrome)?

- Results from injury to the alveolar wall and capillary membrane

- Causes the release of chemical mediators

- Often associated with multiple organ failure

- A severe-life threatening condition

Primary respiratory control centers

Located in the medulla oblongata and the pons of the brainstem, controlling the rhythm and depth of involuntary ventilation.

Central vs. peripheral chemoreceptors

• Central chemoreceptors: Located in the medulla; detect elevated carbon dioxide ($\text{CO}_2$) and hydrogen ion ($\text{H}^+$) levels in cerebrospinal fluid (CSF)\n- Peripheral chemoreceptors: Located in the carotid bodies; sensitive to significant drops in arterial oxygen ($\text{O}_2$)

Hypoxemia vs. hypoxia

• Hypoxemia: Abnormally low concentration of oxygen in arterial blood\n- Hypoxia: Inadequate oxygen supply at the tissue and cellular level

Acute cough vs. chronic cough

• Acute cough: Lasts less than 2 to 3 weeks, usually secondary to self-limiting viral or bacterial infection\n- Chronic cough: Persists longer than 3 weeks, indicating an unresolved or chronic underlying disease process

Cheyne-Stokes respirations

A periodic breathing pattern characterized by alternating periods of deep and shallow breathing, where respirations crescendo and decrescendo between recurring episodes of apnea lasting 15 to 60 seconds.

Kussmaul respirations

Deep, rapid, sighing respirations with an increased rate; classically observed as a compensatory mechanism in severe metabolic acidosis, such as diabetic ketoacidosis.

Stridor

A high-pitched, harsh, crowing inspiratory sound indicating partial obstruction of the upper airway, such as in epiglottitis or foreign body aspiration.

Pleural friction rub

A low-pitched, grating or creaking auscultatory sound produced as inflamed, roughened parietal and visceral pleural surfaces rub against each other during breathing.